Provider Demographics
NPI:1902588627
Name:ELLER, ANNA D (LMT)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:D
Last Name:ELLER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:299 COOPER RD STE B
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-2579
Mailing Address - Country:US
Mailing Address - Phone:770-217-4336
Mailing Address - Fax:
Practice Address - Street 1:299 COOPER RD STE B
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-2579
Practice Address - Country:US
Practice Address - Phone:770-217-4336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-02
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT011178225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist